Vaccines, plus new tests and treatments, are needed to eliminate the scourge of malaria.

analysisBy Gemma Oberth

Two new civil society PRs will implement new and innovative programs

Tanzania has requested $703.4 million from the Global Fund for its HIV, TB and malaria programs as well as for building resilient and sustainable systems for health (RSSH). The country submitted an integrated TB/HIV funding request as well as a malaria/RSSH request, both on 23 May 2017. The TB/HIV funding request was for $426.3 million, of which $38.4 million was a prioritized above allocation request (PAAR). The malaria/RSSH request was for $260.1 million, of which $71.4 million was a PAAR. A matching funds request for $17.0 million was also submitted.

Tanzania proposed an implementation period of 1 January 2018 to 31 December 2020 for all grants emanating from the funding requests.

The funding will be implemented by three principal recipients (PRs): Ministry of Finance, Amref Health Africa and the Benjamin Mkapa Foundation. Both Amref (for TB/HIV) and the Benjamin Mkapa Foundation (for malaria) are proposed as new PRs. Amref will replace Save the Children as the civil society PR for the TB/HIV program. The TB/HIV funding request states the decision was made through a transparent, competitive and participatory process. The Benjamin Mkapa Foundation will join the Ministry of Finance in managing the malaria grant. The malaria/RSSH funding request states that this change is in response to the Global Fund recommendation for dual track financing.

Tanzania's high disease burden and low-income status make it the Global Fund's second largest investment portfolio (next to Nigeria). For the 2017-2019 funding cycle, Tanzania was allocated $579.6 million dollars, representing 5.6% of total Global Fund investment for that period. Tanzania is East Africa's largest country, with an adult HIV prevalence of 5.6%, a TB prevalence of 528/100,000 population, and a malaria prevalence of 15%. Without Global Fund support, Tanzania would be faced with a $1.1 billion shortfall for the three diseases over the next three years, according to the estimated need presented in the funding landscape tables attached to country's funding requests. Even with Global Fund investment, it is clear that a gap will still remain.

Despite this expressed need, the PAAR request for TB/HIV is noticeably small. The Global Fund encourages countries to be ambitious with the PAAR, suggesting they should represent at least 30-50% of the allocation amount. Tanzania's TB/HIV PAAR represents just 7.9% of the within allocation request. This may be a missed opportunity since some of the PAAR activities may be able to be funded through savings made during implementation of the grants in the Global Fund's portfolio, or as additional funding becomes available.

This is the first application Aidspan has come across where the RSSH funding request was integrated into the malaria application. Most 2017 applicants are choosing to integrate RSSH into their TB/HIV applications (including Malawi, Mozambique, Nigeria, Swaziland, Zambia and Zimbabwe). The Global Fund's instructions state that "all applicants are encouraged to submit a joint funding request that includes all eligible components (i.e. RSSH, HIV/AIDS, tuberculosis and malaria, as applicable)." So far, Aidspan is only aware of three countries that have gone with this option (Cape Verde, Sudan and Sao Tome & Principe). Tanzania's choice to integrate RSSH with its malaria request may be because malaria is the leading cause of morbidity and mortality in Tanzania for all age groups, and so can be expected to benefit the most from the RSSH activities.

Tanzania's allocation letter recommends the country maintain or increase its proportional investment in RSSH, which is at 9.3% of its current grants. The letter also provides a benchmark of 10.1% for RSSH investments in Global Fund countries with similar income levels. Ultimately, the country prioritized RSSH below this recommendation: It dedicated $43.5 million to RSSH, representing 7.3% of the country's allocation.

In March 2017, Aidspan reported that several Global Fund-supported programs had been suspended in Tanzania amid tensions around service provision for MSM in particular, though the crackdown also affected service delivery for sex workers (see GFO article). The funding request does not make mention of the suspension of services, instead suggesting that implementation of key population interventions was hindered in the current grant by the absence of relevant guidelines. The country asserts that these guidelines are now available and implementation will be accelerated.

Without addressing the suspension of services for key populations in the current grant, the country requested $18.6 million for comprehensive prevention programs for men who have sex with men (MSM), sex workers, people who inject drugs, and other vulnerable populations, such as mine workers and fisher folk. The request relies on the country's investment case to support the prioritization of services for MSM and sex workers, indicating that an optimal response would require at least 80% coverage of MSM and 50% coverage of sex workers.

Beyond key populations, HIV prevention overall has been given greater weight in the TB/HIV funding request. In total, 12.6% of the request is dedicated to HIV prevention. This is more than double the proportion (5%) that was requested in the country's concept note for the 2014-2016 funding cycle (see GFO article).

For TB, the largest single investment ($9.2 million) of the $31.9 million allocation request is dedicated to covering the costs of drugs for all patients. Another $1.0 million is earmarked for renovating and equipping TB-specific lab infrastructure and procuring lab commodities. The TB/HIV funding request specifically highlights children as a priority key population for TB, aiming to increase childhood case notification to 15% with the Global Fund investment. It also points to the mining sector as an important collaborating partner, proposing an epidemiological study for TB in the mines as well as cross-border linkages with Zambia and Kenya for targeting miners.

More than half ($77.6 million) of the malaria allocation request is dedicated to long-lasting insecticide-treated nets (LLINS). This investment is expected to provide insecticide treatment net coverage at least 85% over the grant period.

The largest single investment of the RSSH request ($10.9 million) will support health facilities to enable them to operate at optimal level and provide comprehensive and integrated services for women, children and adolescents - as per basic health facility standards and in line with the county's quality of care framework. The funding request specifically states that one of Tanzania's priorities is to improve services for pregnant women and children.

Matching funds

Along with a large overall allocation, Tanzania is also eligible for $17 million in matching funds. Of this amount, $8 million is for adolescent girls and young women (AGYW), $6 million for finding missing TB cases, and $3 million for data systems, data generation and data use. The country has met (or exceeded) the 1:1 criteria for all three matching funds categories, dedicating an equal (or greater) portion of its allocation to these priority areas.

In the matching funds request for AGYW, the country proposes some innovative and high-impact approaches. For instance, funding is requested for the design and roll-out of an 18-month pilot project on innovative approaches for the sale and distribution of male and female condoms, such as co-packaging condoms with sanitary towels for AGYW out of school. Cash transfer programs (called "cash plus") are also prioritized, involving scaling up cash transfers and bundling them with health and social services provided to vulnerable families of AGYW. Cash transfers have been shown to have significant impact on reducing new HIV infections among AGYW, primarily by keeping girls in school.

In the matching funds request for finding missing TB cases, the country proposes investing in 106 private motorcycles drivers (called "boda bodas") to strengthen sputum referrals from the peripheral health facilities to those with GeneXpert machines. Funding is also requested to support "sputum fixers" in the 15 regions with the lowest TB detection. Sputum fixers are persons who comb communities in rural Tanzania, asking people who suffer from a cough to give a sample of mucus (sputum), which they then "fix" on a slide and deliver by bicycle to distant laboratories for analysis.

In the matching funds request for data systems, data generation and data use, Tanzania proposes digitalizing the health management information system (HMIS). Two-thirds of the matching funds request is dedicated to this activity. This funding is intended to procure phones, tablets and computers for seven regions of the country, complementing funding for this endeavor provided by the U.S. government and the Gates Foundation in other regions. The funding request refers to the digitalization of HMIS as a "massive investment" where several partners are joining forces to transform the data landscape in the country.

Domestic financing

To sustain the impact of the proposed investments, Tanzania's funding requests point to the National Health Financing Strategy as a key mechanism to increase domestic resources for health. Activities within the strategy include advocating for increased health budget allocation from Ministry of Finance, proposing earmarked taxes or funds, and increasing coverage in health insurance schemes. The requests state that by 2020, government allocations to health will reach 10.5%, and 50% of all Tanzanians will be enrolled in health insurance schemes.

The Technical Review Panel (TRP) met from 19-28 June 2017 to review funding requests submitted in Window 2. The TRP's response to Tanzania's funding request is anticipated this month.

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